Provider Demographics
NPI:1467956276
Name:ODISHO, ROUMTA ASHOR (MD)
Entity Type:Individual
Prefix:
First Name:ROUMTA
Middle Name:ASHOR
Last Name:ODISHO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8860 CENTER DR STE 360
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-7003
Mailing Address - Country:US
Mailing Address - Phone:619-403-5700
Mailing Address - Fax:
Practice Address - Street 1:8860 CENTER DR STE 360
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-7003
Practice Address - Country:US
Practice Address - Phone:619-403-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-19
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA179837207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program